Form 5 National Asian & Pacific Islander HIV/AIDS Awareness Day

Form Approved

OMB No. 0920-New

Expiration Date 00/00/2014

HIV/AIDS Awareness Day Programs

Attachment # 5: National Asian & Pacific Islander HIV/AIDS Awareness Day

Evaluation Report

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Banyan Tree Project Event Summary

Hosting/Planning Organization
Host Agency Name:       Website:      
Address:      
Contact Person:       Phone Number:       E-mail:      
List Collaborating Agencies/Health Departments:      
Event Information
Name of Event:       Date:      
Location/Address:      
Type of Event: (Check all that apply)	Blog Postings /Web-based Community/Panel Discussion Film Screening Fundraising Health or Street Fair/Festival HIV Testing Performing/Visual Arts		Presentation/Training/ /Workshop Press Conference/Briefing Proclamation Athletics/Sports Other(specify):      
Detailed Description of Event:      
Participant Information
Approximate # in attendance:       Age Groups:
Race/Ethnicity: (Check all that apply)	All Asian African-American Latino Middle Eastern/Arab Native American/Alaskan Native Native Hawaiian Pacific Islander White
Behavioral Risk Group: (Check all that apply)	All HIV+ MSM IDU Women Transgender Unspecified Other, specify:      
Other
If HIV Testing provided, # of HIV Tests:       or # of Referrals:      
Did you send out a press release for your event?: Yes No Media Coverage (check all that apply): N/A Television Radio Newspapers Online/Blogs List Stations, Newspapers, Websites, etc.:       Calculate circulation/readership/no. of viewers (if possible):      
Materials:(Check all that apply)	Chapbooks Educational Materials Pens Pledges Posters PSA T-shirts Other:      
Successes/Challenges: Describe with regard to both planning and implementation. Please use complete sentences.
Successes:      
Challenges:      
Attachments: (Please attach to this Form		Blogs/Articles/Etc… Outreach Materials (Flyers, etc…) Photos Presentation/Training Guides Press Releases Other:      

Revised May 5, 2010 Page 4 of 4